Download New York State Infection Control Education

Infection Prevention and Control for
Emergency Response Personnel
Department of Epidemiology, AMC
Rebecca O’Donnell, MT, CIC
Topics
•
•
•
•
Infection Transmission and Prevention Strategies
Ryan White Act
Bloodborne Pathogens
Communicable Diseases and Post-Exposure
Management
• Avian Influenza
• Pandemic Influenza
Chain of Infection
•
•
•
•
•
•
pathogen
portal of exit
portal of entry
reservoir
transmission
host
Routes of Transmission
•
•
•
•
•
Contact: Direct and Indirect
Droplet
Airborne
Vehicle
Vectorborne
Standard Precautions
• Primary strategy for successful nosocomial
infection control
• Applies to:
– blood
– all bodily fluids, secretions, excretions (except sweat),
regardless of whether they contain blood
– non-intact skin
– mucous membranes
Standard Precautions
Key Points:
– Must anticipate contact with bodily fluids
– Select personal protective equipment (PPE) to prevent
skin contact, or soiling of uniform, with bodily fluids
– Correct removal of PPE: gloves, eye protection, gown,
mask
Standard Precautions (PPE)
• Gloves for all anticipated contact with blood,
secretions, excretions, non-intact skin, and
mucous membranes
• Gowns if soiling of clothing is anticipated
• Face shield to protect mucous membranes from
splashing or spraying
Respiratory Etiquette
• Masks for evaluation of patients with respiratory
symptoms
• Mask patient or provide tissues and instruction for
disposal
• Masks for EMS if patient unable to wear mask
• Hand Hygiene
Contact Precautions
• Prevents infections spread by contact route
• Gloves and gown with all patient contact
• Examples: scabies
Droplet Precautions
• Prevents infections spread by large respiratory
droplets
• Surgical masks if within 3 feet of patient
• Examples: bacterial meningitis, influenza
Large Respiratory Droplets
Airborne Precautions
• Prevents spread of infections transmitted via
airborne droplet nuclei
• N-95 respirator
• Examples: TB, measles
Masks
Ryan White Act
• Enacted April 1994
• Disclosure of communicable diseases only to
designated officers
• Diseases:
Infectious pulmonary TB
Meningococcal disease
Hepatitis B
HIV
Diphtheria
Plague
Hemorrhagic fevers
Rabies
Ryan White Requests
EMS Responsibilities
• Request to designated officer (DO) to make
exposure determination
• DO collects facts to determine if exposure meets
established criteria
• DO prepares written request to facility:
– No patient identifying information
– Exposure information needs to be specific
Ryan White Requests
Medical Facility’s Responsibilities
• Exposure determination and ensure enough information
is available
• Medical record review
• Written response within 48 hours
– Does not meet exposure criteria
– Meets exposure criteria and presence or absence of disease
– Insufficient information
• Late diagnosis upon discharge or up to 60 days from
date of transport
Ryan White Requests
Insufficient Information
• Designated officer can request assistance from a
public health official
– Evaluate the designated officer’s request
– Medical facility’s response
• Public Health official must respond within 48 hours
of the request
– Designated officer if insufficient information (can
resubmit if more information is obtained)
– Medical facility if information is sufficient
Source Testing
• There is no provision in the Ryan
White Law that requires source
testing for HIV.
Exposure Incident Definition
• Exposure with blood or other potentially infectious
materials with:
* Mucous membrane or Non-intact skin
(mucocutaneous)
* Bites
* Percutaneous injury with a contaminated sharp
If You Have a Blood or Body Fluid Exposure
• Wash the area with soap and water or flush mucous
membranes
• Notify designated officer (infection control officer)
• Complete a report
• Report for post-exposure evaluation as soon as
possible
Hepatitis B
Hepatitis C
HIV
Affects the liver
Affects the liver
Attacks the Immune
System
Symptoms include
loss of appetite,
fatigue, abd pain,
jaundice
Symptoms include
loss of appetite,
fatigue, abd pain,
jaundice
Early symptoms are
“flu-like”
Can develop into
Cirrhosis or Liver
Cancer
10% become chronic
carriers
Can develop into
Can develop into
Cirrhosis or Liver
AIDS
Cancer
85% become chronic
carriers
Hepatitis B
Pre-exposure
vaccine
Hepatitis C
No pre-exposure
vaccine
HIV
No pre-exposure
vaccine
Post-exposure:
Post-exposure:
Immune Globulin for No effective
unprotected HCWs prophylaxis
Post-exposure:
Anti-retro viral
therapy
Risk after
percutaneous
exposure is
31%
Risk after
percutaneous
exposure is
0.3%
Risk after
percutaneous
exposure is
1.8%
Hepatitis B Vaccine
• 1-2 months following completion of 3 dose vaccine
series HBsAb titer should be obtained from health
care worker
• Non responders should complete second series* or
be evaluated to determine if they are HBsAgpositive
• Minimal side effects
*30% - 50% chance of responding to the second series
Prevention of Bloodborne Diseases in Health
Care Workers through Engineering and Work
Practice Controls
Avoiding occupational blood exposures is the
primary way to prevent transmission of Hepatitis B,
Hepatitis C and HIV in health care settings.
Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV,
AND HIV and Recommendations for Postexposure Prophylaxis, 6/2001
Needlestick Injuries
• CDC estimates 600,000 percutaneous injuries per
year
• 62 - 88 % could be eliminated by using safer
medical devices
Needlestick Safety and Prevention Act, 11/00
Work Practice Controls
Work practice controls must be implemented to
eliminate or reduce the likelihood of exposure
to potentially infectious material
Active Device: Retractable Safety IV Stylet
Active Device: Safety -Lok Butterfly
Diseases that Require Post-Exposure
Management
• Airborne or droplet transmission
TB
Pertussis
Rubella
Varicella
Rubeola
Mumps
Invasive meningococcal disease
• Contact transmission (all employees)
– Scabies
• Bloodborne: Hepatitis B and C, HIV
Exposure Investigations
Tuberculosis
•
•
•
•
•
•
Exposure criteria based on clinical presentation
No exposure follow up for persons with latent TB
Baseline PPD
12 week PPD
Induration of > 5 mm is conversion for known exposures
INH for 9 months post-exposure for converters (reduces
risk of disease from 10% to 1%)
Pertussis
• Causative agent: Bordetella Pertussis
• URI, paroxysms of cough, “whoop”, post-tussive
vomiting, apnea in children < 6 months
• Persistent cough in adults
• Transmits via contact with respiratory secretions
and droplet (mask patient for transport)
Exposure Investigations
Pertussis
• Exposure defined as contact with respiratory
secretions when barriers were not used or face-toface exposure during a coughing attack without the
use of a mask
• Asymptomatic exposed health care workers: no
work restrictions but prophylaxis required
• Symptomatic exposed health care workers:
Exclude from work until 5 days of effective
treatment
Types of Meningitis
• Viral
• Fungal
• Bacterial:
–
–
–
–
Meningococcal
Streptococcus Pneumoniae
Invasive Haemophilus influenzae
Gram positive and gram negative organisms
Only meningococcal meningitis requires post-exposure management
Invasive Meningococcal Disease
• Causative agent: Neisseria meningitidis
• Meningitis, meningococcemia, primary pneumonia
• Can be recovered from the respiratory tract of
asymptomatic carriers
• Droplet transmission (mask patient for transport)
• Abrupt onset, high fever, meningitic symptoms,
petechial rash
• Gram negative diplococci on gram stain
Exposure Investigations
Invasive Meningococcal Disease
• Exposure defined as contact with respiratory secretions
when barriers were not used
– Mouth-to-mouth resuscitation
– Intubation or extubation
– Suctioning
• Rifampin, Ciprofloxacin or Gatifloxacin within 24 hours
of exposure
Scabies
• Causative agent: Sarcoptes Scabiei
• Cutaneous infestation with pruritic rash
– Rash commonly found between fingers and in “warm
areas” of body
– Itching intensifies at night
– Rash progresses without treatment
• Use gloves and gown if necessary to avoid contact
with rashes
Exposure Investigations
Scabies
• Occupational exposure defined as skin-to-skin
contact with an infested patient
• Occupational exposures: CDC vs. NYSDOH
• Asymptomatic health care workers: no work
restrictions but prophylaxis required
• Symptomatic health care workers: Work
restrictions until 24 hours after treatment (Norwegian)
Avian Influenza A (H5N1)
• A subtype of the influenza virus that mainly occurs
in birds.
• More than 200 human cases have been reported.
• There was no sustained human-to-human
transmission.
Avian Influenza: Why such a threat?
• Surface proteins on the virus will not be recognized by
human respiratory cells.
• Avian flu infects humans at a low frequency but has
huge pandemic potential.
• WHO and other organizations are watching Asia and
other countries with avian outbreaks very closely.
Avian Influenza A (H5N1)
Symptoms
• Range from typical influenza-like symptoms (fever,
cough, sore throat, and muscle aches)
• Eye infections
• Pneumonia, acute respiratory distress, viral
pneumonia
• Other severe and life threatening complications
What is an Influenza Pandemic ?
 A global influenza outbreak
- Caused by a brand new (novel) flu virus
 Because it is a new virus, few or no people would be
immune and many people would get sick in every part
of the world
 Economical impact in U.S. $71.3-$166 billion
Martin M, Cox N, Fukunda K. The Economic Impact of Pandemic Influenza in the United States:
Priorities for Intervention. Emerging Infectious Diseases 1999; 5: 659-671.
Principles of Infection Control for Pandemic
Influenza
• Contain respiratory secretions
• Limit contact between infected and noninfected persons
• Promote spatial separation in common areas
Community-Based
Infection Control Strategies
• Social distancing
– Snow days, voluntary self-shielding
• Cancellation of public events
– concerts, sports events, movies, plays
• Closure of schools and workplaces
– office buildings, shopping malls
• Closure of recreational facilities
– community swimming pools, youth clubs, gymnasiums
Masks
• Recommended for:
– healthcare workers with
direct patient contact
– symptomatic persons
– contacts of ill persons
• Benefit of wearing masks by well persons in public settings
has not been established.
WHO Pandemic Phases
Emergency Medical Services:
Inter-pandemic Phase
• Key Factors:
– Reinforce infection control practices
• promoting annual influenza vaccination
• proper use of PPE
– Communication
• County EMS coordinator
• Local Health Department
• NYSDOH
Emergency Medical Services: Pandemic
Alert phase
• Key Factors:
– Reinforce infection control education and training
– Ill staff should not report to work
– Designate a contact person to receive updates from the local health
department.
– Develop a plan for enhancing staffing
– Vaccination
• Develop internal plan to immunize all direct patient care providers and essential staff in a
short period of time.
– Antiviral medication
• Develop a plan to provide antiviral medication for prophylaxis and or treatment of all direct patient
care providers.
• Levels of priority staff needs to be established as antivirals may be limited.
Emergency Medical Services:
Pandemic period
• Key Factors:
– Identify agency resources that may be (or become) limited. (Staff, medical
supplies, PPE)
– Monitor/identify critical gaps in ability to provide emergency medical services.
Communicate with EMS coordinator and local health department.
– Antiviral medication
• Implement plan to provide antiviral medication for prophylaxis and/or treatment of all
direct care providers.
• Levels of priority staff needs to be established as antivirals may be limited.
Specific Pre-hospital Care
• Follow standard and droplet precautions when transporting
symptomatic patients.
• Consider routine use of masks for all patient transport when
pandemic flu is in the community.
• Unless medically necessary to support life, aerosol-generating
procedures (mechanical ventilation) should be avoided.
• Optimize vehicle’s ventilation to increase volume of air exchanges
during transport.
• Notify the receiving facility that a patient with possible pandemic flu
is being transported
• Follow standard operating procedures for routine cleaning of the
emergency vehicle and reusable patient care equipment.
Websites
•
•
•
•
•
•
www.health.state.ny/nysdoh/ems/policy/policy.htm
www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm
www.health.state.ny.us
www.cdc.gov
www.cdc.gov/flu/avian/index.htm
www.pandemicflu.gov